Complications of the postpartum period
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Complications of the Postpartum Period. Hemmorhage. Early postpartum hemmorhage >500 ml in first 24 hrs (blood loss often underestimated) Late or delayed >500 cc after first 24 hrs. Predisposing factors. Uterine overdistension--large infant,etc. Grand multiparity Anesthesia or MgSO 4

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Complications of the Postpartum Period

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Complications of the Postpartum Period


Hemmorhage

  • Early postpartum hemmorhage

    • >500 ml in first 24 hrs (blood loss often underestimated)

  • Late or delayed

    • >500 cc after first 24 hrs.


Predisposing factors

  • Uterine overdistension--large infant,etc.

  • Grand multiparity

  • Anesthesia or MgSO4

  • Trauma

  • Abnormal labor pattern--hypo or hypertonia

  • Oxytocin during labor

  • Prolonged labor

  • Hx of maternal anemia, hemorrhage


Prevention

  • Risk assessment

  • Inspect placenta

  • Explore uterus

  • Avoid overmanipulation of uterus

  • If at risk type and Xmatch and start IV


Signs of Impending Hemorrhage

  • Excessive bleeding (>2pads/30min-1hr)

  • Light headedness, nausea, visual disturbances

  • Anxiety, pale/ashen color, clammy skin

  • Increasing P and R, BP same or lower


Actions to take

  • Summon help

  • Check uterine tone, massage, assess effect

  • Elevate legs, lower head

  • Increase or begin O2

  • Increase or begin IV


Early Postpartum Hemorrhage

Within the first 24 hrs

  • Causes

    • uterine atony

    • lacerations

    • retained secundines

    • coagulation problems


Uterine atony

Failure of the uterus to stay firmly contracted

  • Slow, steady or massive hemorrhage, sometimes underestimated or hidden behind a clot

  • VS may not change immediately

    Treatment

  • bimanual massage

  • oxytoxics

  • curretage

  • surgery iliac ligation or hysterectomy


Retained placenta or fragments

Partial separation caused by:

  • pulling on the cord

  • uterine massage prior to separation

  • placenta accreta

    Treatment:

  • massage

  • manual removal

  • oxytoxics

  • D & E


Hemorrhage occurring after 24 hrs

retained placenta--necrosed, fibrin deposits, placental polyps, sloughingbleeding

Symptoms

excessive or bright red bleeding

boggy fundus

large clots

backache

T-P-R, BP

Late postpartum hemorrhage

Treatment, massage, IV oxytocin, D&E


Hematomas

Result from injury to a blood vessel, usually in vagina or vulva, may extend upward into broad ligament or other pelvic structures

  • develop rapidly

  • may contain 300-500ml blood


Symptoms

  • Severe pain

  • Difficulty voiding

  • Mass felt on vaginal exam

  • Flank pain

  • Abdominal distension

  • Shock


Treatment

  • Ice

  • I & D (incision and drainage)

  • Packing


Subinvolution

Uterus remains large, does not involute

Causes, retained placental fragments, infection

Symptoms:

  • Lochia fails to progress

  • Returns to rubra

  • Leukorrhea with backache and infection

    Treatment:

  • methergine

  • curretage

  • antibiotics


Puerperal Infection

Definition:

Temp of 101o or more in the first 24 hrs following delivery

Temp of 1004 or higher on any 2 of the first10 pp days (with the exception of the first 24 hrs)


Types of Infections

  • Endometritis

  • Parametritis

  • Peritonitis

  • Pyelonephritis

  • Cystitis

  • Thrombophlebitis

  • Mastitis, abcess


Predisposing Factors

Antenatal factors

  • poor nutrition

  • low SES

  • Hx of Infections

  • Anemia

  • Immunodeficiency


Intrapartum predisposing factors

  • Prolonged labor

  • PROM

  • Poor aseptic technique

  • Birth trauma

  • Multiple exams

  • Internal monitoring

  • Episiotomy

  • C section


Postpartum Predisposing Factors

  • Manual removal of placenta

  • Hemorrhage

  • Retained secundines


Aerobic 30%

B hemolitc strep

E.coli

Klebsiella

Proteus

Pseudomonas

Staph

Anerobic 70%

Bacteriodes

Peptococcus

C. perfringes

Causative Organisms


Localized

  • Episiotomy

  • Lacerations

  • C section incision


Endometritis

Infection of the endometrium

  • placental site

  • decidua

  • cervix

    Symptoms--discharge (scant to profuse), bloody, foul smelling

    uterine tenderness

    jagged, irregular temp elevations

    tachycardia, chills, subinvolution


Salpingitis, Oopheritis

May be caused by gonorrhea, chlamidia

  • unilateral or bilateral abd pain

  • chills, fever

  • mass

  • tachycardia

  • may lead to sterility


Pelvic Cellulitis, (parametritis)

Infection of the connective tissue of pelvis

  • frequently infecting the broad ligament and causing severe pain.

  • May ascend from cervical lacerations


Parametritis symptoms

  • Spiking temp to 104

  • chills, flushing, sweating

  • tachycardia, tachypnea

  • uterine tenderness, cramping

  • change in LOC/agitation,delerium, disorientation

  • change in lochia

  • cervical or uterine tenderness on vag exam

  • WBC elevation


Peritonitis

Life threatening infection of the peritoneum

  • Abcesses on the uterine ligaments, in the cul de sac, and/or in the subdiaphragmatic space

  • May result from pelvic thrombophlebitis


High temp

chills

malaise

lethargy

pain

subinvolution

Tachycardia

local or referred pain

rebound tenderness

thirst

distension

nausea and vomiting

Symptoms of Peritonitis


Cystitis

Bladder infection

  • urgency

  • frequency

  • burning

  • dysuria

  • suprapubic pain

  • hematuria


Pyelonephritis

Kidney infection, usually of the R. kidney.Ascends from bladder.

  • Spiking temp

  • Shaking chills

  • Flank pain, CVA pain

  • Nausea and vomiting

  • Hx of asymptomatic bacteruria or pyelonephritis

  • Urgency, frequency, dysuria

  • Back pain


Prevention and treatment

  • Force fluids

  • Insure complete emptying of bladder

  • Sterile technique for cath

  • Good perineal care

  • Antibiotics


Thrombophlebitis Blood clot associated with bacterial infection

Etiologies

  •  blood clotting factors

  • postpartal thrombocytosis (platelets)

  • thromboplastin release (placenta, amnion)

  • fibrinolysin and fibrinogen inhibitors


Tenderness

heat

redness

low grade fever

+ homans sign

tachycardia

Treatment

elevation

heat

TEDs

analgesic

bedrest?

Antibiotics?

Superficial


Symptoms

edema

low grade fever

chills

pain in limb below affected area

“milk leg”

decreased peripheral pulses

Dx--doppler

Tx:

heparin to coumadin

antibiotics

TEDs

bedrest

elevation

analgesics

Deep Vein Thrombosis


Symptoms--sudden onset

dyspnea

sweating

pallor

cyanosis

confusion

hypertension

cough/hemoptysis

Tachycardia

SOB

 Temp

 jugular pressur

chest pain

sense of impending death

pressure in bowel/rectum

Pulmonary Embolisman Obstetrical emergency


Treatment

  • Call MD

  • O2

  • Demerol

  • Papaverine or other “clot busters”

  • Aminophylline

  • heparin

  • Streptokinase


Disseminated Intravascular Coagulation (DIC)

  •  prothrombin and platelets

  • widespread formation of intravascular clots

  • clotting factor expended

  • severe generalized hemorrhaging

    Life threatening!


Etiologies

  • Septic shock

  • placental/uterine hemmorhage

  • IUFD

  • Amniotic fluid embolism

  • thrombi secondary to preeclampsia

  • thrombi secondary to thrombophlebitis


Early signs of DIC

  •  protime

  •  fibrinogen

  • thrombocytopenia

  • bleeding from gums

  • bleeding from puncture sites

  • ecchymosis

    Treatment complex, packed cells, fibrinogen, whole blood, plasma


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